FORM A

Application Form

2018Nagaoka Summer School for Young Engineers (NASSYE)

NagaokaUniversity of Technology

Note to Applicant: This application form consists of four pages. Type or print clearly.

  1. Name: ,

Family name First name Middle name

2. Nationality: 3. Gender: □Male □Female

4. Date of Birth:

5. Age:

6. Contact Information:

* If you plan to move, give both your present address and future address and show valid periods.

Current Address:

Telephone/Facsimile Number:

E-mail Address:

7. Your Current Status:

Name of Home Institution:

Field of Study:

Program Enrolled(check one):

□Undergraduate Program

□Other (Please specify: )

8-1. Outline of your research and career interest:

*Additional sheets of paper may be attached if necessary.

8-2. Please describe your future plan, if you are interested in pursuing a graduate education in Japan and/or our university in the future.

9. Educational Background

*Please indicate your educational background from High School to higher education including graduate level.

**If the blank spaces below are not sufficient for information required, please attach a separate sheet.

Name of Institution / Date of Entrance (M/Y) / No. of Years
Attended / Diploma or Degree Awarded
Location of Institution / Date of Graduation (M/Y) / Major Subject

10. Employment Record:

*Begin with the most recent employment and exclude part-time work..

Name of Organization / Period of Employment / Position / Type of Work
Location of Organization / Month/Year
From
To
From
To
From
To

11.Japanese language proficiency:

Evaluate your Japanese proficiency level and insert an X where appropriate in the following blank space.

Excellent / Good / Fair / Poor
Reading
Writing
Speaking

12.English proficiency: Check onewhere appropriate in the following Standardized English Proficiency Test and write test score. Please submit a copy of test score report.

□TOEFLScore:

□TOEICScore:

□IELTSScore:

□Cambridge EnglishScore:

13. Research topic: Write a preferred research topic (s) of your interest. (Please refer to List of Research Topics for 2018 Nagaoka Summer School for Young Engineers.)

Preferred Research Topic:

I understand that withholding pertinent information requested in this application form or giving false information will make me ineligible for admission or will make me liable to dismissal. Bearing this in mind, I certify that the above statements are correct and complete.

Signature: Date:

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